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PRACTICE

forensic dentistry

A look at forensic dentistry —


Part 1: The role of teeth in the
determination of human identity
I. A. Pretty,1 and D. Sweet,2*

Forensic dentistry can be defined in many ways. One of the more


In brief
elegant definitions is simply that forensic dentistry represents the • Forensic dentistry plays a major role in
overlap between the dental and the legal professions. This two-part body identification
series presents the field of forensic dentistry by outlining two of the • Several methods of dental identification
exist
major aspects of the profession: human identification and bite • DNA use in forensic dentistry
marks. This first paper examines the use of the human dentition and • Case examples of dental identifications
surrounding structures to enable the identification of found human
remains. Conventional and novel techniques are presented.
Dental identification of humans occurs
for a number of different reasons (Table 1)
s we enter a new millennium, society is high degree of certainty) that the remains of and in a number of different situations.3
A faced with fresh challenges in every
conceivable area. Despite leaps in modern
a decedent and a person represented by
antemortem (before death) dental records
The bodies of victims of violent crimes,4,5
fires,6 motor vehicle accidents and work
technology, medical breakthroughs and the are the same individual. Information from place accidents,7 can be disfigured to such an
geographical changes that the last century the body or circumstances usually contains extent that identification by a family mem-
has brought, crime still persists in all aspects clues as to who has died. Secondly, in those ber is neither reliable nor desirable.8 Persons
of our lives. Violent and heinous activities cases where antemortem records are not who have been deceased for some time prior
that shatter the lives of victims, their friends available, and no clues to the possible iden- to discovery and those found in water also
and families occur everyday. Often, little can tity exist, a postmortem (after death) dental present unpleasant and difficult visual iden-
be done to repair such damage. The appre- profile is completed by the forensic dentist tifications. Dental identifications have
hension and subsequent prosecution of the suggesting characteristics of the individual always played a key role in natural and man-
perpetrator(s) is essential to maintain law likely to narrow the search for the ante- made disaster situations and in particular
and order. Through the specialty of forensic mortem materials.2 the mass casualties normally associated with
odontology, dentistry plays a small but sig-
nificant role in this process. By identifying
the victims of crime and disaster through Table 1 Common reasons for identification of found
dental records, dentists assist those human remains
involved in crime investigation. Always part
of a bigger team, such personnel are dedi-
cated to the common principles of all those Criminal Typically an investigation to a criminal death cannot begin
involved in forensic casework: the rights of until the victim has been positively identified
the dead and those who survive them.
The most common role of the forensic Marriage Individuals from many religious backgrounds cannot remarry
dentist is the identification of deceased indi- unless their partners are confirmed deceased
viduals.1 Dental identification takes two
main forms. Firstly, the most frequently Monetary The payment of pensions, life assurance and other benefits
performed examination is a comparative
relies upon positive confirmation of death
identification that is used to establish (to a
Burial Many religions require that a positive identification be made
1Graduate Student, University of Liverpool, UK; prior to burial in geographical sites
2*Director, Bureau of Legal Dentistry, University of
British Columbia, Canada Social Society's duty to preserve human rights and dignity beyond
*Correspondence to: David Sweet, 146-2355 East
Mall, University of British Columbia, Vancouver, BC,
life begins with the basic premise of an identity
Canada V6T 1Z4
email: dsweet@interchange.ubc.ca Closure The identification of individuals missing for prolonged periods
REFEREED PAPER
Received 22.12.99; Accepted 24.07.00
can bring sorrowful relief to family members
© British Dental Journal 2001; 190: 359–366

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forensic dentistry

available (ie wallet or driving licence may be


found on the body) and this will enable
antemortem records to be located. In other
instances, the geographical location in
which the body is found or other physical
characteristics and circumstantial evidence,
may enable a putative identification to be
made, frequently using data from the miss-
ing persons’ database. Antemortem records
are then obtained from the dentist of record.
The forensic dentist produces the post-
mortem record by careful charting and
written descriptions of the dental structures
and radiographs (Fig. 1). If the antemortem
records are available at this time, post-
mortem radiographs should be taken to
replicate the type and angle of these.13 Radi-
ographs should be marked with a rubber-
dam punch to indicate antemortem and
postmortem to prevent confusion — one
hole for antemortem films and two holes for
postmortem films.
Once the postmortem record is com-
plete, a comparison between the two
records can be carried out. A methodical
and systematic comparison is required,
examining each tooth and surrounding
Fig. 1 An example of postmortem dental charting
structures in turn. While dental restora-
tions figure significantly in the identifica-
tion process, many other oral features are
aviation disasters.9–12 Because of the lack of Typically, human remains are found and assessed (Table 2), and these play an
a comprehensive fingerprint database, dental reported to the police who then initiate a increasingly important role in those indi-
identification continues to be crucial in the request for dental identification. Often a viduals with minimal restorations. Because
United Kingdom. presumptive or tentative identification is of the progressive decrease in dental caries,

Comparative dental identification


Many people are familiar with the concept
of dental identification; it is frequently men-
tioned on television news. But the nuances
and complexities of the process are rarely
understood. The central dogma of dental
identification is that postmortem dental
remains can be compared with antemortem
dental records, including written notes,
study casts, radiographs, etc, to confirm
identity. Clearly, individuals with numerous Postmortem (September 1990) Antemortem (August 1985)
and complex dental treatments are often
easier to identify than those individuals with Fig. 2 An example of the comparison of postmortem and antemortem radiographs to determine
identity. The pattern, shapes and sizes of individual dental treatments present in one record are
little or no restorative treatment. The teeth compared with similar traits and characteristics in the other record. In this case it was determined
not only represent a suitable repository for that the records originated from the same person. This established a positive identification. Note
such unique and identifying features, they that there are several discrepancies present, (eg endodontic treatment of teeth LR5 (45) and
also survive most postmortem events that LR6(46) in the postmortem record) but these can be explained as a result of the time interval
between the two records and the additional dental treatments performed during this period
can disrupt or change other body tissues.2

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Table 2 Features examined during the comparative dental identification. This extensive list
represents the complexity of these cases, particularly in those instances in which
restorative treatment is absent or minimal

Teeth Pulp chamber/root canal morphology Alveolar process and lamina dura
a. size, shape and number a. Height, contour, density of
Teeth present
b. Secondary dentine crestal bone
a. Erupted
b. Thickness of interradicular bone
b. Unerupted Pulp chamber/root canal pathology
c. Exostoses, tori
c. Impacted a. Pulp stones, dystrophic calcification d. Pattern of lamina dura
Missing teeth c. Root canal therapy e. Bone loss (horizontal/vertical)
a. Congenitally d. Retrofills f. Trabecular bone pattern and bone
b. Lost antemortem e. Apicectomy islands
c. Lost postmortem Periapical pathology g. Residual root fragments
Tooth type a. Abscess, granuloma or cysts
a. Permanent b. Cementomas
c. Condensing osteitis Anatomical features
b. Deciduous
c. Mixed Dental restorations Maxillary sinus
d. Retained primary 1. Metallic a. Size, shape, cysts
e. Supernumerary a. Non-full coverage b. Foreign bodies, fistula
b. Full coverage c. Relationship to teeth
Tooth position
a. Malposition 2. Non-metallic Anterior nasal spine
a. Non-full coverage a. Incisive canal (size, shape, cyst)
Crown morphology b. Laminates b. Median palatal suture
a. Size and shape c. Full coverage
b. Enamel thickness 3. Dental implants Mandibular canal
c. Contact points 4. Bridges a. Mental foramen
d. Racial variations 5. Partial and full removable prosthesis b. Diameter, anomalous
c. Relationship to adjacent
Crown pathology
structures
a. Caries
b. Attrition, abrasion, erosion Periodontal tissues Coronoid and condylar processes
c. Atypical variations, Gingival morphology and pathology a. Size and shape
enamel pearls, peg laterals etc. a. Contour, recession, focal/diffuse, b. Pathology
d. Dentigerous cyst enlargements, interproximal Temperomandibular joint
Root morphology craters a. Size, shape
a. Size b. Colour – inflammatory changes, b. Hypertrophy/atrophy
b. Shape physiological (racial) or pathological c. Ankylosis, fracture
c. Number pigmentations d. Arthritic changes
d. Divergence of roots c. Plaque and calculus deposits
Other pathologies
Root morphology Periodontal ligament morphology a. Developmental cysts
a. Dilaceration and pathology b. Salivary gland pathology
b. Root fracture a. Thickness c. Reactive/neoplastic
c. Hypercementosis b. Widening d. Metabolic bone disease
d. Root resorption c. Lateral periodontal cysts and e. Focal or diffuse radiopacities
e. Root hemisections similar f. Evidence of surgery
g. Trauma – wires, surgical pins etc.

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a c
Antemortem panoramic radiograph
Fig. 3 Example of a comparative dental
identification case. The body depicted in the
images is that of a sixteen-year-old female.
She was found encased in a waterbed frame
after being reported missing for over a year. A
victim of homicide, she became mummified in
the dry, cool conditions under the bed. The
bed, used frequently, was removed when a
lodger left the apartment and the body was
discovered. Despite the condition of the soft
tissues the teeth remain in perfect condition.
The antemortem and postmortem
radiographs are shown below. A positive
identification, this case illustrates a non- d
restorative case. Note the mesiodens
Postmortem full-mouth radiographic survey

so-called non-restorative cases are likely to • Positive identification: The antemortem cient detail to render a positive conclu-
become more common.14 and postmortem data match in sufficient sion.16 The discretion of identification lies
Similarities and discrepancies should detail, with no unexplainable discrepan- with the odontologist who must be pre-
be noted during the comparison cies, to establish that they are from the pared to justify the conclusions in court,
process.15 There are two types of discrep- same individual. surely the ultimate in peer-review. Figure 3
ancy, those that can be explained and • Possible identification: the antemortem illustrates a case of dental identification.
those that cannot. Explainable discrepan- and postmortem data have consistent fea-
cies normally relate to the time elapsed tures but, because of the quality of either Postmortem dental profiling
between the antemortem and post- the postmortem remains or the ante- When antemortem dental records are
mortem records. Examples include teeth mortem evidence, it is not possible to unavailable and other methods of identifi-
establish identity positively.
extracted or restorations placed or cation are not possible, the forensic dentist
• Insufficient evidence: The available infor-
enlarged (ie MO amalgam that is now can assist in limiting the population pool to
mation is insufficient to form the basis for
MOD). Figure 2 illustrates explainable which the deceased is likely to belong and
a conclusion.
discrepancies. If a discrepancy is unex- • Exclusion: the antemortem and post- thus increase the likelihood of locating ante-
plainable, for example a tooth is not pre- mortem data are clearly inconsistent. mortem dental records.2 This process is
sent on the antemortem record but is known as postmortem dental profiling. The
present on the postmortem record then It is important to note that there is no information from this process will enable a
an exclusion must be made. minimum number of concordant points or more focused search for antemortem
A range of conclusions can be reached features that are required for a positive iden- records. A postmortem dental profile will
when reporting a dental identification. The tification. In many cases a single tooth can typically provide information on the
American Board of Forensic Odontology be used for identification if it contains suffi- deceased’s age, ancestry background, sex
recommends that these be limited to the fol- cient unique features. Equally, a full-mouth and socio-economic status. In some
lowing four conclusions:16 series of radiographs may not reveal suffi- instances it is possible to provide additional

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advocate third molar use claim an accuracy


of ±4 years.27 Middle-aged and older adults
present difficulties. Periodontal disease pro-
gression, excessive wear, multiple restora-
tions, extractions, bone pathosis and
complex restorative work may indicate an
older individual. Accuracy using these
highly-variable markers is in the range of
±10–12 years. Some odontologists advocate
the use of aspartic acid racemization, claim-
ing an accuracy of ±4 years.28 Additional
a
methods include the use of SEM-EDXA, a
method used to examine dentine in relation
to age determination. A recent study from
Fig. 4 (a) Shovel-shaped incisors and (b) the Cusp of Carabelli
are both dental indicators for ethnicity the UK examined the use of root length in the
b
determination of age in paediatric cases.29
The presence of erosion can suggest alco-
information regarding occupation, dietary actual developmental stages of the teeth are hol or substance abuse, an eating disorder or
habits, habitual behaviours and occasion- more accurate. Third molar development is even hiatus hernia while stains can indicate
ally on dental or systemic diseases. used by some forensic dentists to assign age smoking, tetracycline use or betel nut chew-
Forensic anthropologists most often pro- to young adults although doubts concern- ing.30–39 Unusual wear patterns may result
vide details of osteological studies, but foren- ing the accuracy of this technique will be from pipe stems, cigarette holders, hairpins,
sic dentists can assist in the process.17–22 The raised by the practitioner’s own experience carpet tacks or previous orthodontic treat-
determination of sex and ancestry can be of the variability of these teeth.26 Those who ment.2,40 The quality, quantity and presence
assessed from skull shape and form. Gener- or absence of dental treatment may give an
ally, from skull appearance, forensic dentists indication of socio-economic status or likely
can determine race within the three major country of residence (Fig. 5).41 Figure 6
groups: Caucasoid, Mongoloid and Negroid. shows an example of postmortem dental
Additional characteristics, such as cusps of profiling.
Carabelli, shovel-shaped incisors and If the postmortem profile does not elicit
multi-cusped premolars, can also assist in the tentative identity of the deceased it may
determination of ancestry (Fig. 4).23 Sex be necessary to reconstruct the individual’s
determination is usually based on cranial appearance during life. This is the respon-
appearance, as no sex differences are appar- sibility of forensic artists who use the
a
ent in the morphology of teeth. Microscopic dental profile to help with the facial repro-
examination of teeth can confirm sex by the duction.
presence or absence of Y-chromatin and
DNA analysis can also reveal sex.24, 25 Other methods of dental
Dental structures can provide useful indic- identification
tors to the individual’s chronological age.22 The two processes described above, com-
The age of children (including foetuses and parative identification and postmortem
neonates) can be determined by the analysis profiling, represent the most common
of tooth development and subsequent methods of dental identification. However,
comparison with developmental charts. in some instances more novel and innova-
Conclusions are usually accurate to approx- b tive techniques have been applied. There
imately ±1.5 years. Charts such as those Fig. 5 The quality and type of dental have been a number of requests from indi-
developed by Ubelaker graphically illus- treatment may indicate an individual's viduals and dental organizations over the
trate the development of the dentition from country of residence: a) Dental treatment of years to insist that dental prostheses are
high quality, which is consistent with North
5 months in utero to 35 years, illustrating American and European standards.
labelled with the patient’s name or a unique
the deciduous, mixed and permanent denti- b) Unusual dental treatments involving the number.42 The NHS provide a fee for den-
tions.2 It is important to note that when use of permanent acrylic and stainless steel tists who label their patients dentures,
determining sub-adult ages, eruption dates crowns. This treatment was performed in although this is often only used in instances
Russia
of the teeth are highly variable and the where the wearer is a resident in a care home

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or other establishment with a central steril- most forensic applications, (there are no authors have found that even root-filled
izing system for dental prostheses. Labelled nuclei, and hence there is no DNA, in red teeth supply sufficient biological material
dentures can be of great assistance in the blood cells.) When body tissues have for PCR analysis!48
identification of individuals.43 decomposed, the structures of the enamel, PCR-based analysis produces a DNA pro-
Unlabelled dentures have been recovered dentine and pulp complex persist. It is nec- file that can be compared with known ante-
from patients and then fitted to casts essary to extract the DNA from the calcified mortem samples or paternal DNA. Figure 8
retained by the treating dentist or labora- tissues. In the authors’ laboratory, the cryo- illustrates a case using DNA from teeth to
tory, and this has been an accepted method genic grinding method is employed determine the identity of found remains.
of identification.44 Other dental appliances, (Fig. 7).48 Teeth represent an excellent The identification of individuals is not the
such as removable orthodontic braces have source of genomic DNA. Indeed, the only use for dental DNA. The technique has
also been used for identification purposes.
Whittaker describes a case where a remov-
able orthodontic appliance was used to
identify a victim of a house fire.45 Authors
have also described the use of palatal rugae
patterns rendered on dental casts to com-
pare with found remains. Positive identifi-
cations have resulted from this technique.46
Dental materials have provided clues to
assist identification. One of the authors (DS)
has used SEM-EDX to identify the composi-
tion of a glass-ionomer restoration and then c
traced this back to a prison where the filling was
placed. Dental records secured the identifica-
tion of the individual. In another case, it was
possible to identify Kevlar fibers that had been
placed within a lower denture to reinforce it.
This rare procedure enabled an identification
of the wearer who was a victim of homicide.

Role of DNA in dental identifications


Because of the resistant nature of dental tis- a
sues to environmental assaults, such as
incineration, immersion, trauma, mutila- d
tion and decomposition, teeth represent an
excellent source of DNA material.47 When
conventional dental identification methods
fail, this biological material can provide the
necessary link to prove identity.48 With the
advent of the polymerase chain reaction
(PCR), a technique that allows amplifica-
tion of DNA at pre-selected, specific sites,
this source of evidence is becoming increas-
ingly popular with investigators. Compari-
son of DNA preserved in and extracted from
the teeth of an unidentified individual can b e
be made to a known antemortem sample
(stored blood, hairbrush, clothing, cervical Fig. 6 A postmortem profiling identification case. Investigators were unable to establish a
tentative identification and requested a postmortem dental profile. The skeletal pattern and
smear, biopsy, etc) or to a parent or sibling.2 dental characteristics suggested the following profile: Caucasian, male, aged 25–35 years at
death, moderate adult periodontitis, nicotine stains, lack of recent dental treatment and
Genomic DNA previous treatment to Canadian standards. Using this information, a forensic artist produced
Genomic DNA is found in the nucleus of a facial reproduction. Subsequently, the body was identified as that of a 28-year-old missing
white male smoker
each cell and represents the DNA source for

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tine comparative dental identification, but


the inherent problems are magnified.53
Problems of body fragmentation, mutila-
tion, commingling and incineration, idio-
syncratic dental records from numerous
regions, poor working conditions and psy-
chological stresses all confound the identifi-
cation process. The key to successful mass
disaster identification is preparedness.54
Many jurisdictions have dental identifica-
Fig.7 Cryogenic grinding is used to extract DNA from calcified tissues such as teeth. In a freezer tion teams and disaster plans in place. Mock
mill a ferromagnetic plunger is oscillated back-and-forth in alternating electric current. Liquid disaster scenarios that help dentists prepare
nitrogen is used to cool the sample, which results in making it extremely brittle and also for the disaster situation have proven to be
protects DNA from heat degradation. The tooth is reduced to a powder to increase surface
area and expose trapped cells to biochemical agents that release DNA into solution
successful.54,55

allowed criminal investigators to link vic-


tims to crime scenes once the body has been
removed and incinerated.49

Mitochondrial DNA
In addition to genomic DNA, cells contain
mitochondrial DNA (mtDNA), the
sequence of building blocks of which can
be determined to assist in identification.
The main advantage of mtDNA is that
there is a high copy number in each cell
caused by the high number of mitochon-
dria present in most cells. This infers that Teeth recovered from body (1999)
in cases where genomic DNA cannot be
Fig. 8 The use of DNA from teeth to
analyzed, possibly because it is too prove identity. Circumstantial evidence
degraded, mtDNA may be present in suffi- established the probable identity of a found
cient quantity. In addition to its higher human skull. Antemortem dental records
were not available for comparison.
copy number, mtDNA is maternally inher- Medical records revealed the availability of a
ited.50 This maternal inheritance pattern Pap (cervical) smear. Partial degradation of
confers the same mtDNA sequence, bar- DNA from teeth produced a profile at
ring mutations, upon siblings and all their eight genetic loci. These were compared
with the DNA profile obtained from the Pap
maternal relatives. This has important smear and established that the samples
implications for the identification of indi- originated from the same source
viduals for which there is no antemortem Pap smear (1992)
comparison sample. Although mitochon-
drial DNA is still in its infancy in forensic
casework, it is a powerful technique that is
likely to become commonplace in the
future.

Dental identification in mass


disasters
The identification of large numbers of casu-
alties in mass disasters are complex and
fraught with hazards, both physically and
emotionally.51,52 The identification process
is fundamentally the same as that in a rou- DNA profile from Pap smear DNA profile from teeth

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